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中国筛查和控制高血压脑血管血管危险因素总体控制
中国高血压概况
在中国，心血管病是公共健康的首要问题，心血管病每年约夺去260万人的生命和造成年致残数约28,369,00人。数个全国范围有代表性调查资料显示，过去的30年，中国人群中心血管危险因素水平已显著上升，这是造成包括脑卒中和冠心病在内主要心血管病患病率及死亡率增高的基本原因。根据全国第三次血压普查资料，大约有1亿高血压患者，而高血压知晓率仅为26.3%，治疗率为12.1%，控制率仅有2.8%。总吸烟率男性63%、女性3.8%，甚至青少年男性吸烟率也有16.7%。据推断2000年大概有80万人死亡与吸烟有关。中国人的血清总胆固醇水平存在明显地区间差别，与大多数西方国家相比平均血清胆固醇水平较低，但中国是在人群中总胆固醇水平有明显升高趋势的少数国家之一。脑卒中的高发生率和死亡率、冠心病的发生率和死亡率升高、目前人群中已有冠心病危险因素的绝对数量极大，且仍有增多的趋势，都是心血管疾病预防面临的挑战。
1999年秋，世界卫生组织和健康研究全球论坛联合创建发展中国家心血管健康的倡议。
倡议以降低血压作为其急待优先解决的问题，采取针对广大人群和高危因素人群的方式。其首要目标为开发能负担得起的筛查项目和健康教育及治疗项目、并且对效果、可接受性及费用进行评估。
在中国选定控制血压为急需的目标，因为它是心血管病的重要决定因素，并且给广大地区控制心血管病的主动行动提供了起点。
中国于1959、1979及1991年都进行了全国血压普查，患病率（高血压定义为收缩压140mmHg、及/或舒张压90mmHg）1991年为11.9%，明显高于1959年的5.11%及1979年的7.73%。
我国高血压筛查
自1999年，作为价格/效益的较好方法，建议以偶测血压筛查确定高血压病人。
总计有950,356名15岁以上者参加1991年第三次全国血压调查，回应率为89.49%。
调查项目有：测血压、脉搏、身高、体重以及健康常识，和家族与个人心血管病史。
质量控制措施包括：
◎ 建立指导委员会和技术委员会以促进并保证调查成功；
◎ 操作手册，由科学筛查委员会制订、供所有研究组使用，其中详细叙述设计、实施以及国际标准方法；
◎ 选用并组织好多阶段群体样本，以保证地区人群样本有良好代表性；（除台湾外，461个城市，1904个乡镇）选出274个样本；
◎ 在全国和地区两级进行了人员培训，参加调查工作前全体参加培训者必须取得资格证书；
◎ 调查期间也关注质量控制，组成15个专家和质控人员小组分赴各省调查区域监察实施情况；
◎ 1991年调查时间根据当地气温决定，以避开过冷或过热季节；
◎ 资料管理中心建立；资料输入程序供各地区输入资料使用，所有资料都输入2次，用这些质控措施，全部调查获取了一套良好的资料，在950337份问卷调查中仅0.31‰和0.74‰有逻辑性遗漏资料的错误，939138（98.82%）血压读数中25.8%为0、19.1%为2、18.5%为4、17.3%为6、19.2%为8作为尾数，仅0.13%有奇数尾数。
1991年结果显示：确立高血压为5.29%，临界高血压5.90%，总患病率为11.19%，显著高于1959的5.11%及1979年的7.73%。由于在卫生部的统一领导下，地区干部、专家和小组成员通力合作、以及电脑分析的重大进展，本研究的全过程具有设计良好、精心组织、较好队伍培训及优质的质控等特点。
1999年在10,000门诊病例中进行偶测血压筛查，设计为收集已利用健康保健系统的病人资料，本科研项目的目的为确定这些疾病人群中对高血压的知晓率、目前治疗成功率、及医学信息的来源。从中发现，关注这组已享受医疗权的病人，能开发一项专注于干预的预防医学项目，此种干预能要求以最小的资源得到最大的影响。
心血管疾病社区预防
心血管病社区基础的综合预防研究在3个城市和一个农村社区40万人中进行，自1992年1995年卫生知识调查显示社区干预有显著进步，通过高血压控制、健康促进、限制饮食中胆固醇和盐等措施，心血管病患病率和死亡率有所下降。
心血管病社区基础的综合预防研究目标为探讨40万人群中综合干预对降低心血管病发生率和死亡率的效果。具体措施包括：营养干预、健康促进、高血压病人管理，监测心血管病发病和死亡趋向，尤重视35岁以上人群。在"八五"计划期间，社区基础综合预防共有40万人，分别在北京、上海和长沙的3个城市社区和北京郊区房山的一个农村社区进行，每个社区人群分为干预社区和对照二组，其人文和经济情况具可比性。结果：4年后二组比较，社区干预组卒中发生率与死亡率分别下降21.4%和33.2%，对照组分别下降6.2%和24.7%；1992至1995，社区干预组卒中发生率和死亡率分别平均为180.34/10万和116.09/10万，对照组分别为203.57/10万和135.75/10万；同期，社区干预组急性心肌梗死和冠心病发生率和病死率分别为46.3%和32.8%，对照组分别为59.6%和44.8%；社区干预组收缩压下降2.39mmHg，高血压病人服药率自15.4%增至26.3%，血清总胆固醇降低0.11~0.30mmol/L；吸烟率城市社区降低0.9%，乡村社区下降6.6%，食盐摄入量女性人群减少367mg；社区干预显示知识、态度和行为都有明显改善。
心血管病社区预防措施：
1．营养干预、
2．健康促进、
3．高血压病人管理，
4．监测心血管病发病和死亡趋向。
心血管病社区预防结果：
1． 卒中、急性心梗、冠心病的发生率和死亡率干预组明显低于对照组。
2． 高血压病人服药率增高
3． 血清总胆固醇降低
4． 吸烟率降低
5． 食盐摄入量减少
职工健康筛查
仅少数企业能够每2年为职工进行健康筛查，监测心血管病、糖尿病、肿瘤。
有些企业能够每2年为职工提供健康筛查，以青岛港口健康研究为例，1500名18～64岁职工曾每2年被调查详细病史、体格检查、生活方式询问及实验室检查，一些新的诊断技术也用于调查，如超声心动描记术（一种心脏超声检查）、颈动脉超声，所有在调查中发现的高血压或糖尿病患者将加以管理，一切心血管、卒中及肿瘤（死亡或非死亡）事件都进行监测。
我们因过去30年对心血管病奋斗取得的积极成果和最近实施的1999年发展中国家心血管健康倡议受到极大鼓舞，然而，我们充分认识到面对的现实，并将继续面对可预见未来的挑战是严峻的。在世界人口最多的发展中国家，中国，对心血管病预防和控制的一切研究项目在物质、财政及人力资源方向受到严重限制是不可避免的问题，目前全国正全力以赴以求达到经济可持续发展，为将我国建成强大、现代化经济国家需要几代人通力协作，我们要准备工作，努力工作，以有限的资源争取可能的最好结果。
Screening and control of hypertension in China
Liu Lisheng
In China, Cardiovascular diseases (CVD) are emerging as the major public health problem. CVD claim about 2.6 million lives each year and cause about 28,369,000 disability adjusted life year (DALY). The data from several cross-sectional nationwide surveys show that levels of risk factors of CVD in the Chinese population has risen significantly over the past 30 years, which has been the basis for the increasing morbidity and mortality of major CVD, including stroke and coronary heart diseases. According to the Third National Survey of Blood Pressure, there were about 100 million hypertensive patients but the awareness rate was 26.3%, the treatment rate was 12.1% and the control rate was only 2.8% for hypertension. The total smoking rate was 63% in men，3.8% in women. Even in male teenagers, smoking rate was 16.7%. It was predicted that there would be 800, 000 deaths related to smoking in 2000. There were significant regional differences in the average levels of serum total cholesterol in China. The average serum cholesterol level is lower compared with most western countries, but China is among the few countries which experience a significant increasing trend for total cholesterol in the population. The challenges for CVD prevention are higher levels of incidence rate and mortality rate of stroke, the increasing incidence rate and mortality of coronary heart disease, the current already huge absolute numbers of people with CVD risk factors and still their increasing trends.(1)
In the fall of 1999, WHO and the Global Forum on Health Research jointly launched the Initiative for Cardiovascular Health in the Developing Countries.(2)
The Initiative has adopted blood pressure lowering as its immediate priority, addressing both the population-wide approach and the high-risk approaches. Its initial objectives include development of affordable screening programs, heath education and treatment programs, and evaluation of efficacy, acceptability and cost.
In China, blood pressure control is chosen as the immediate target, since it is an important determinant of the CVD and it provides a starting point for wider regional initiatives in CVD control.
In China, National blood pressure surveys were carried out in 1959, 1979 and 1991. The prevalence rate (hypertension defined as SBP 3 140mmHg and /or DBP 3 90mmHg) was 11.19% in 1991, definitely higher than 5.11% in 1959, and 7.73% in 1979.
Since 1999, opportunistic blood pressure screening was recommended as a more
cost/effective way for identifying hypertensive patients(3).
A total 950,356 participants aged 15 and over were examined in the Third National Survey of Blood Pressure in 1991, with a response rate of 89.49%. Survey items included measurement of blood pressure, pulse rate, height, weight and health knowledge as well as family and personal history of cardiovascular disease (CVD). Measures for quality control involved: (1) Establishment of a steering committee and a technical committee to promote and guarantee the success of the survey; (2)An Operation Manual describing design, implementation, and internationally standardized methods in detail was developed by the Scientific Screening Committee and used by all the survey teams; (3) Multistage cluster samplings were employed and well organized in order to guarantee a good representation of samples for local population. 274 samples were selected from all over the nation (461 cities and 1904 rural counties except Taiwan ). (4) Personnel training was done on two levels; national and local. All the interviewers must obtai
n a certificate before participating in the survey; (5) Attention was also paid to quality control during the survey. Fifteen groups of specialists and quality control personnel were sent to survey fields in different provinces to monitor the implementation; (6) Time of survey in 1991 was decided according to the local temperature to avoid extremely cold or hot seasons. (7) A program for data input was developed in the Data Management Center and used by all the local centers for data entry. All data were entered two times. With all these quality control measures, a good data set for the whole survey was obtained. Among the 950337 questionniares, only 0.31‰ and 0.74‰ had logic missing data error. Among 939138 (98.82%) blood pressure readinngs, 25.8% had 0, 19.1% had 2, 18.5% had 4, 17.3% had 6, and 19.2% had 8 as terminal digit. Only 0.13% had an odd terminal digit.
The results showed that the established hypertension is 5.29%, borderline hypertension 5.90%, and the total prevalence rate was 11.19% in 1991, which was definitely higher than 5.11% in 1959, and 7.73% in 1979. The whole process of the study was characterized by its better design, better organization, better team training and better quality control due to the unified leadership under the Ministry of Public Health, the great combined effort of the local officers, specialists and team workers and the big progress in computer assisted data analysis.
In 1999 an opportunistic blood pressure screening(4) among 10,000 out-patient clinic subjects was designed to gather data on patients already utilizing the health care system. The objective of this project was to determine the awareness of hypertension, the rate of success of current treatment, and the source of medical information in this patient population. It was found that by focusing on this group of patients, who already had medical access, a preventive medical program could be developed to focus on interventions that would have the largest impact with the least resources required.
Community-based comprehensive prevention of CVD was implemented in 400,000
people in three urban and one rural communities. From 1992 to 1995 KAB showed a significant improve in the intervention community. There was a lowering in
morbidity and mortality of CVD, by taking measures of hypertension control, health
promotion, dietary cholesterol an sodium restriction (5).
The community-based comprehensive prevention of CVD study aimed to explore the comprehensive intervention effect on lowering incidence and mortality of CVD in 400, 000 population. Measures included intervention of nutrition, health promotion, management of Hypertensive patients; monitoring the trend of incidence and mortality of CVD, especially in the population aged above 35. Community-based comprehensive prevention was implemented in 400,000 people in three urban communities in Beijing, Shanghai and Changsha respectively, and in one rural community in Fangshan, a Beijing suburb, during the period of "The Eighth Five-Year Plan". Each community population was divided into two parts, an intervention community and a control community demographically and economically comparable. Results: Incidence and mortality of stroke decreased by 21.4% and 33.2%, respectively, in the intervention communities after four years, as compared with those of 6.2% and 24.7%, respectively, in the control communities. Stroke Incid ence and mortality averaged 180.34 and 116.09 per 100,000 respectively in the intervention communities; 203.57 and 135.75 per 100,000 respectively in the control communities during 1992 - 1995. Incidence and mortality of acute myocardial infarction and coronary heart disease was 46.3%, 32.81, respectively, during 1992-1995 in the intervention communities; 59.6%, 44.8% respectively in the control communities. In the intervention community, systolic blood pressure decreased by 2.39 mmHg, the rate of taking medicine among hypertensive patients increased from 15.4 to 26.3%. The total serum Cholesterol decreased by 0.11-0.30 mmol/L. The smoking rate decreased by 0.9 % in urban communities, and 6.6% in rural communities and the dietary sodium intake decreased by 367mg in female population. Knowledge, Attitude and Behavior showed a significant improvement in the intervention community.
Only few industries can afford health screen for employees biannually, and monitoring of CVD, DM as well as cancer events.
Some industries can afford Health Screen for employees biannually. The Qingdao Port Health Study(6) is an example. 1500 employees aged 18-64 have been surveyed every two years for a detailed medical history, physical examinations, lifestyle interviews and laboratory tests. Some new diagnostic technologies are also involved in the survey, such as echocardiography (an ultrasound exam of the heart), carotid artery ultrasound. All patients with hypertension or diabetes discovered by the survey will be managed, all events of CVD, stroke and cancer (fatal and non-fatal) are monitored.
We have been rightly encouraged by the positive results we have achieved in combating CVD in the past 3 decades and more recently in implementing the 1999 Initiative for Cardiovascular Health in Developing Countries. However, we are fully aware that the challenges we face at present and will continue to face in the foreseeable future are tremendous. In China, the world's most populous developing country, all projects to prevent and control CVD are inevitably subject to serious limitations in terms of material, financial and human resources. At present, the whole nation is going all out to achieve sustainable economic development. It will take the concerted efforts of several generations before our country will build up a strong, modernized economy. We must be prepared to work, and to work hard, with limited resources and yet strive for the best possible results.
References
1. Dong Zhao, Cardiovascular Risk Factors and Their control in China;
2. Prof. K. Srinath Reddy on behalf of CVD Research Initiative. Introducing CVD Research Initiative in the Developing Countries.
3. PRC National Blood Pressure Survey Cooperative Group, A summary on the 1991 national sampled study on Hypertension in China et al. Chinese Journal of Hypertension; 1995 Apr 3(Suppl).
4. Liu Lisheng, MD, Blood Pressure Status in Patients attending Hospital Clinics in the People's Republic of China; Preliminary Results of the 1999 Blood Pressure Survey Project; CVD Prevention volume 2, Number 4, December 1999; 305
5. Li Shichuo, Wang Wenzhi, Wu Shengping, et al. Effects of Community-based Comprehensive Prevention on Incidence and Mortality of Stroke et al. Chinese Journal of Preventive Medicine; Volume 32, February 28, 1998
6. Hongye Zhang. Brief Introduction of Qingdao Port Health Study.
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